|
Eligible participant has to fullfill all of the following items | / / / / / / / |
|
Anyone with one of following items or more should be excluded: | / / / / / / / / / / |
- General information
- Medical history
- Physical examination
- Blood Routine Tests
- Urine Routine Test
- Blood Electrolytes Tests
- Coagulation Function Tests
- Serum Liver Function Tests
- HBV/HCV/HIV/Syphilis Markers Test
- Renel Function Test
- D-dimer
- hCG Test
- Image Examinations
- Visual Analogue Scale
- Blood Gas Analysis
|
Date of signing the informed consent | 2024-1-31 |
|
Date of birth | 2011-09-15 yyyy-mm-dd |
|
Age | 12 Years |
|
Education background | Primary school
|
|
Occupation | Other
|
|
Other (Description) | 学生 |
1天加重3小时 小时 |
|
无 |
|
|
Number of pregnancy | 0 次 |
|
Number of delivery | 0 次 |
|
If has delivery history, select following items | |
|
partus maturus | -- 次 |
|
premature delivery | -- 次 |
|
abortion | -- 次 |
|
Last pregnancy | -- yyyy-mm-dd |
|
Average times of menstrual onset a year | 12 次/年 |
|
Average menstrual cycle | 6.5 天(days) |
|
Menarche time | 11 岁(years) |
|
The time of last Menstruation | 2023-12-31 年、月、日(yyyy-mm-dd) |
|
The time of menstrual onset before the last one | 不详 年、月、日(yyyy-mm-dd) |
无 |
|
-- 年/月/日（yyyy-mm-dd） |
|
|
Namy of the drug to be allergied | -- |
|
Vulva | Normal
|
|
Description in detail for abnormal | -- |
|
Vagina | Not examined
|
|
Description in detail for abnormal | -- |
|
Uterine neck | Not examined
|
|
Description in detail for abnormal | -- |
|
Corpus uteri | Not examined
|
|
Description in detail for abnormal | -- |
|
Adnexa uteri | |
|
Left side | Not examined
|
|
Description in detail for abnormal | -- |
|
Right side | Not examined
|
|
Description in detail for abnormal | -- |
|
Weight | 57 kg |
|
Hight | 1600 mm |
|
Systolic pressure (SP) | 92 mmHg |
|
Diastolic pressure | 63 mmHg |
|
Temperature | 36.3 degree Celsius |
|
Pulse rate | 104 次/分 |
|
Breath frequency | 23 次/分 |
|
Doctor signature | 刘义彬 |
|
Date | 2024-1-31 yyyy-mm-dd |
|
WBC | 6.80 ×109 /L |
|
NEUT% | 76.99 % |
|
LY% | 10.97 % |
|
MONO％ | 11.36 ％ |
|
RBC | 4.68 ×10^12 /L |
|
HGB | 130 g/L |
|
PLT | 323 ×10^9 /L |
|
Researcher signature | 刘义彬 |
|
Date | 2024-1-31 yyyy-mm-dd |
|
Acidity and allkalinity | |
|
pH value | -- |
|
Urine protein | |
|
Urine red cell | |
|
Urine WBC | |
|
Urine glucos | |
|
Urine Bilirubin | |
|
Urine HCG | |
|
KET | |
|
SG | -- |
|
UBG | |
|
NIT | |
|
Date of test | -- yyyy-mm-dd |
|
Date of test | 2024-1-31 yyyy-mm-dd |
|
K | 4.04 mmol/L |
|
Na | 139.3 mmol/L |
|
Cl | 103.2 mmol/L |
|
Ca | 2.40 mmol/L |
|
P | 1.35 mmol/L |
|
Date of examination | 2024-1-31 yyyy-mm-dd |
|
Prothrombin time | 12.9 秒 |
|
Thrombin time (TT) | 13.8 秒 |
|
Activated partial thromboplastin time (APTT) | 28.0 秒 |
|
Fibrinogen (FIB) | 3.38 g/L |
|
ALT | 17.2 IU/L |
|
AST | 16.7 IU/L |
|
GGT | 6.0 U/L |
|
Serum bilirubin | 11.80 μmol/L |
|
Indirect bilirubin | 7.60 umol/L |
|
Direct bilirubin | 4.20 umol/L |
|
Serum albumin | 44.2 g/L |
|
Serum globulin | 30.5 g/L |
|
Serum total protein | 74.7 g/L |
|
Date of test | 2024-1-31 yyyy-mm-dd |
Negative
|
|
|
Date of test | 2024-1-31 yyyy-mm-dd |
Negative
|
|
|
Date of test | 2024-1-31 yyyy-mm-dd |
Negative
|
|
|
Date of test | 2024-1-31 yyyy-mm-dd |
Negative
|
|
|
Date of test | 2024-1-31 yyyy-mm-dd |
|
SCr | 53.0 μmol/L |
|
Blood urea | 4.30 mmol/L |
|
Blood uric acid | 319.0 μmol/L |
|
Date of test | 2024-1-31 yyyy-mm-dd |
|
D-dimer value | 0.13 ug/mL |
|
Date of test | 2024-1-31 |
|
Urine pregnancy test | Not tested
|
|
Blood HCG concentration | -- mIU/mL |
|
Date of test | -- yyyy-mm-dd |
|
Size of the ulcer | 5.13*4.71*4.06 cm*cm |
|
Uterine echo distribution | Even
|
|
Endometrial thickness | 12.1 mm |
|
Left ovary size | 3.52*1.92 cm ×cm |
|
Shape of Left ovary | Normal
|
|
Size of the Ovarian cyst | -- |
|
Right ovary size | 3.52*2.48 cm ×cm |
|
Shape of right ovary | Ovarian cyst
|
|
Size of Ovarian cyst | 7.78*8.59*6.26cm |
|
Description of other abnormal findings | -- |
|
Diagnosis of the Ultrasound B | 卵巢囊肿蒂扭转 |
|
Doctor signature | 刘义彬 |
|
Date of examination | 2024-1-31 yyyy-mm-dd |
|
Pain Visual Analogue Score | Very pain
|
|
PH | 未查 |
|
PCO2 | 未查 mmHg |
|
P02 | 未查 mmHg |
|
SO2 | 未查 ％ |
|
HCO3 | 未查 mmol/l |
|
SBE | 未查 mmol/l |
|
LAC | 未查 mmol/L |
|
Date of examination | -- (yyyy-mm-dd) |
右卵巢 |
|
7*6*5 cm |
|
逆时针360° ° |
|
| / | |
刘义彬 |
|
2024-1-31 |
|
D-dimer value | 0.16 ug/mL |
|
Date of test | 2024-2-1 |
|
Body temperature | 37 ℃ |
|
Systolic pressure (SP) | 92 mmHg |
|
Diastolic pressure (DP) | 63 mmHg |
|
Heart Rate, HR | 82 次/分 |
|
Pulse | 82 次/秒 |
|
WBC | 5.2 ×109 /L |
|
NEUT% | 78.68 % |
|
LY% | 9.19 % |
|
MONO％ | 11.95 ％ |
|
RBC | 4.05 ×10^12 /L |
|
HGB | 114 g/L |
|
PLT | 247 ×10^9 /L |
|
Date | 2024-2-1 yyyy-mm-dd |
| / | |
|
Pain Visual Analogue Score | Occasionally very slight pain
|
|
sample collection | Collected
|
|
Volume | 1 ml |
|
Time of collection | 2024-1-24/2024-2-1 yyyy-mm-dd-hh-min. |
|
Label Number of the sample | 2561848 |
|
Date received at DCC | -- yyyymmdd |
|
Report type | |
|
Name of this event | -- |
|
SAE start date | -- yyyymmdd |
|
SAE stop date | -- yyyymmdd |
|
Was this an unanticipated adverse event | |
|
Attribution to Study Drug | |
|
Outcome Type(check all that apply) | |
|
Recovery Description: (check only one) | |
|
Please provide a brief narrative of the SAE occurrence below | -- |
|
Name of the recorder | -- |
|
Data | -- yyyymmdd |
|
Site Investigator’s signature | -- |
|
Data | -- yyyymmdd |